Q: How does one figure out whether they are plural? We’ve, or I’ve, been in constant doubt about this for almost half a year now. I know this is a broad and difficult question.

The best advice we can give here is to attempt the tulpa creation process. This is where we started and a month later, we had Lilith fronting for the first time. For ourselves and many others we know who were already plural, the tulpa creation process went much faster than timelines given by the guides. By this point, we can create a tulpa in a few days if we want and know many others with DID who can do the same. The tulpa creation process covers many aspects of internal communication such as creating an innerworld and learning to speak with each other and contains most of what is needed to make existing headmates aware of each other. If you are like us, just going through this process can awaken existing headmates and open channels of communication between them and bring dormant plurality to life. We have not looked at them in detail, but know there are excellent guides at tulpa.io.

Q: What’s it like having tulpas as well as alters? Do tulpas act differently than alters? Is there a hierarchy within your system? Are alters considered ‘higher up’ or given more credit over tulpas?

This touches one of the core values of our system – we are all equals, regardless of origin. We do not differentiate between tulpas, alters, soulbonds, and other labels and instead choose to group everyone together under the label headmate. Labels trying to classify headmates cause confusion for us rather than bringing clarity because many of us have no clear label which fits them. For example, one time during an anxiety attack, we intentionally split Esther into two with one part holding all the anxiety and the other part being much calmer. The part who held the anxiety could be classified as an alter since she could be classified as a trauma split but would also fit the definition of tulpa since she was intentionally created. We put Esther back together a few hours later, but this example demonstrates how trying to fit each of us into boxes can be unhelpful. The only classifications we use are “trauma holder” and “non-trauma holder” because that provides direction for our healing and helps indicate who can help with healing and who is in need of healing. We treat each other as equals and everyone has equal rights to the body and operate on a principal of compromising to maximize happiness and minimize harm.

Including subsystems, there are over 100. We are polyfragmented so our system size readily expands when under stress. We believe this has been the case since early childhood and expect our system size to increase indefinitely. The list of us is here.

We created our system with the goal of being able to love, care for, and protect each other. This has made it easy for us to compromise on what will make everyone happiest and agree on what to do, even if some individuals want something else. Doing this allows us to work heavily towards minimizing harm to each other and the end result has been that we have never had any significant disagreements where we could not find an acceptable compromise relatively quickly. Together, we help protect and care for each other and the end result is that we are capable of so much more working together and helping each other than any of us would be alone.

Q: What factors came together to allow you to be comfortable being out as plural at work?

The main thing was the number of ways we are “different” made us decide early on that it was easier to be out as everything than to try and hide everything. We are trans (transfeminine genderfluid), polyamorous, panromantic, asexual, Autistic, plural, and so on. By the time we started exploring our plurality, we were openly trans at work and also openly poly. We had worn our collar to work and at times attached our badge to it. Coming out as one more thing was just another part of us being weird rather than us going from “normal” to “different”.

We also came out little by little. When we first discovered our plurality, we initially just stared using plural pronouns at work. This resulted in a couple comments, but nothing bad happened. The next step was to come out at pride which resulted in us being more out. The next step was national coming out day which was the first time we explicitly invited questions. When we decided to be fully out was when we wrote a playbook about DID at work for teammates, managers, and plural systems. At each of these steps, the feedback from our coworkers was positive and coming out little by little gave us a lot of space to go back into the closet if anything went wrong.

We also had X months worth of expenses by the time we came out so were in a financial position where we could tolerate a single job loss. If losing our job would have been catastrophic, we would not have come out.

Q: How do y’all feel confident enough to expose your plurality as part of your public interface? Are y’all concerned about economic or social disincentives from society at large, or from other pluralities who have the opportunity to judge you?

We came out gradually over time. At this point, we have been out for over two years at our tech job and have not been fired yet so we aren’t concerned about the economic disincentives. We are a disabled queer and once we bear the social costs of belonging to that group, being out as plural has a negligible effect. For us, the cost of repressing our plurality or other identities outweighs any costs we have to pay as the result of expression so coming out was an easy decision for us.

Q: Do headmates have independent gender identities or is gender considered a property of the system as a whole? How does genderfluidity affect individual headmates?

Each of us comes with their own name and gender. Genderfluidity is more a property of the system than any one system member since Lucia is the only individual who would identify as genderfluid. In terms of system members, we are ~75% female, ~23% gender neutral, and ~2% male. In terms of fronting time, we are ~50% female, ~50% gender neutral, ~0% male. We know that our male headmates are not thrilled with what we have done to the body, but they understand that transitioning was needed to improve the stability of our system as a whole. We have a breast binder so when our male headmates come out, they can hide our breasts and hope this will encourage them to front more when we begin to explore this part of our system. The male parts of our system are mostly unexplored at this point so we know that we will have a lot of work to do when we do finally begin to dig into this.

Q: How long does it take to change who is fronting? If it’s a non-trivial amount of time, what happens to the body during the process?

It takes us about a second and up to 5 seconds if we want to do a “harder” switch (ie. push others completely away from front while taking front). We know others where it’s more of a slow transition between fronters over several hours, but we have always been able to do this near instantaneously.

Q: How do you manage daily tasks – for example, are all of you software engineers, or does one particular headmate or subset of headmates have to front to get work done? Are there tasks that some are not capable of, and does one headmate have to ask for help or does a front-switch happen whenever a task is better suited for another?

There are definitely some of us who are better at certain tasks. For example, Lucia tends to do much more of the software engineering than others. That doesn’t mean that others can’t do software engineering, it just means that when the task which needs to be done is related to software engineering, it tends to draw Lucia to front. Exactly how much skill sharing exists is something we have not explored deeply. It’s rare that we try and front lock (have only a single person at front) so we have not been able to test the boundaries of exactly what headmates can and can’t do. We do have vague plans to give luna, our 6 year old, a trial run to see if she can code so this is something we do want to play with in the future.

When things are going well, we seamlessly rotate as needed and no explicit switch is needed because we can have over half a dozen of us around at the same time. When we are under a lot of stress, we tend to front lock and explicitly negotiate who is going to front next, how long they believe they can hold front for, and who is going to take over for them when they can’t hold front any more. A common pattern here is that someone will take over in the morning before work and then we will switch to someone else on the way home. This allows us to keep stress from work from following us home when we aren’t in a good state.

Q: Are there secrets that you (the current front) don’t want other headmates to know?

We are highly co-conscious and have very strongly shared event memory so there are no secrets we keep from each other and we are not sure we even could keep a secret from each other. In general, we would approach keeping secrets from each other the same way we would approach keeping a secret from a partner – if we feel we need to keep something secret from our partner, it means it’s time to explore those feelings and communicate the result of these explorations with our partner.

Q: I’d be curious if different headmates would answer these questions differently.

Each of us uses their own tone of voice and we often have different things we pay most attention to so different headmates would definitely answer these questions differently – Emma

More than that, each of us has stronger access to different emotional states so the emotional states associated with each of us would cause us to answer these questions differently – Serenity

Some of us come from a perspective of survival much more than others and some come from the perspective of helping others. I am a healer so belong to that last group so my answers would be different from others – Lilith

The best DID support forum we have found online is Mosaic Minds. It’s small and relatively inactive, but is the only DID focused forum we have found which we felt very comfortable at. The tulpa.io forums are welcoming of traumagenic or mixed-origins systems, though there is a tulpa focus there. We know and deeply trust many of the people who run that site and can definitely recommend it as a safe space.

Q: Have you or do you want to externally change anything about your body, appearance, or dress, in order to outwardly express your plurality in a way that someone who’s singular wouldn’t normally do?

We do think about this, just like how we have desires to express our gender in interesting ways. Every time we think about this, we always decide that it’s not worth the energy which we would have to put into it, especially since we don’t have very much energy to begin with. This is something we list as a nice to have which we would definitely explore if we had infinite time and energy, but it’s never been important enough to us that we actually do it.

There are a few exceptions to this, early on, we sometimes wore dresses to bring out Lilith since dresses are much more closely associated with Lilith than Lucia. Lucia’s pendant also helps bring out LuciaOfTheBlueStar when we wear it. We have also used colors in the past to bring out headmates such as wearing a bright purple shirt to bring out Aerie, our cheshire cat. In general, we do minor things like this when they naturally fit into what we are already doing, but don’t find putting more energy into this to be worthwhile.

Q: How do we be friends with you and be able to talk to you without being intimidated? Without feeling scared that it’d be a chore and a drain on you to even speak to you? Why does the thought of trying to talk to you make us so so scared all the time? Sorry… just don’t know where or what else to ask…

The simplest way is to just say hi to us. It’s ok to just tell us that you are intimidated by us, it won’t bother us at all to hear that. We find explicit communication like that to be incredibly useful and is definitely one of the things we look for in friends. It definitely won’t be a chore for us to talk to you. It may be draining at times and the amount of spoons we have for socialization varies over time. We definitely go through periods of expansion and contraction of our social circles and have to carefully watch how many spoons we are spending on friends to ensure we keep our mania in check. If we do end up in a period of contraction, we will explicitly say that we don’t have spoons for talking and give an estimated timeline of when we do expect to have spoons. If the timeline changes, we will also give updates since we believe strongly in explicit communication. We don’t know why thinking about talking to us makes you scared, but if it’s something you want to talk about with us, we are open to having that conversation ^=.^

Q: You talk about the body’s parents. Is all the family out of your lives? Has there been any attempt to explain to them or would they in any way support you?

We have explained our plurality to them and have received zero support (but also zero active hostility). This was the same reaction they had when we came out as trans so it was exactly what we expected. It still disappointed us because we still would like to create a relationship with the body’s parents, but we recognize it is unlikely they will ever make any significant effort to understand who we are so that is unlikely to happen.

Q: Do different front identities experience different physical attributes or reactions? Greater strength, reaction time, sensitivity to light or touch, arousal, etc? Asked another way, is DID purely a mental thing, or does it affect the shared body as well?

Plurality definitely affects the body beyond the mind. For example, darkLilith is the one of us who holds the most PTSD of all of us so she has the sharpest anxiety reactions, including the most visible anxiety reactions in the body. Astra and Yggdrasil are some of the best in our system at entering calm states so the body tends to be much calmer and relaxed when they are around. We definitely know a system where some of them are sexual and others are not. Our two hypnotists, Aerie and luna tend to have much more active roles in general and the body definitely reflects the higher energy states as well.

This is well documented in the medical literature: “A third general principle is that switches between states are manifest by non-linear changes in a number of variables. These variables include… regulatory physiology” (Putnam, 1988).

Q: If you’re comfortable talking about it and remember the details, could you share a bit more about the type(s) of trauma you experienced that led to the splits between the different people in your system?

We are trans and Autistic and bipolar and in general our mental health disabilities force us to be very careful about overexertion. Even today, this is something we have to very actively and consciously manage our energy. While grocery shopping with one of our partners, they said we made ourselves manic enough to go grocery shopping. This stuck with us and we now state that we have to make ourselves manic enough to do our job and go take care of chores like grocery shopping while simultaneously keeping our mania sufficiently in check that we are not headed towards a psychotic break.

We were raised in a guess culture household with a parenting style which was reasonably close to the “tiger mom” style. We looked at our therapy notes from 7th grade and in there, the body’s father describes us as unmotivated and when asked about grades, we were described as having “all A’s last year and one B this year”. Within the last 5 years, we witnessed the body’s father yelling at our brother and calling him lazy and related pejoratives because he was getting B’s and was “only” going to get into a Cal State rather than a UC. This parenting style combined with our overall low energy level and the lack of recognition of any of our disabilities resulted in us being constantly pushed beyond what we were reasonably capable of. Being bipolar meant we could make ourselves manic enough to meet what the body’s parents wanted from us and our capacity for dissociation meant that we could break again and again and still continue to have some level of functionality. Specific traumas:

Before age 8: we have no memories of this, but given our bad home situation, we would be surprised if there was not a significant amount of emotional trauma related to being pushed beyond our limits. One of the more insidious pieces of guess culture is that nobody explains to you that guess culture exists so combined with our Autism, we were unable to predict the body’s parents’ reactions to things we did. This last bit continued throughout our entire life.

Age 8: here, we had nightmares about being stuck in an elevator and often sleepwalked during these nightmares. We avoided elevators whenever we could for many (5+) years after this. With our current knowledge, we can easily classify these as PTSD symptoms and it’s frustrating that nobody around us noticed or did anything to help us. We have no memory of what the source of this trauma is, but have vague plans to go digging for these memories in the near future.

Age 10-11 (4th/5th grade): There were many artsy craftsy school projects to show off at open house during these years. The body’s mother would take all creative control of these projects and we would be sitting next to her trying to fulfill her vision, knowing we would be yelled at if we didn’t do it closely enough. The only thing we could do here was to dissociate during this. The headmate who has the most PTSD, darkLilith, is 10 years old, indicating she is directly attached to this trauma and holds many of these memories.

Middle school (age 11-14): We spent these years emotionally dead, feeling no emotion except anger (because it is socially acceptable for boys to express anger). Due to the body’s parents philosophy that any time spent doing nothing meant we were “lazy”, we used video games to overstimulate ourselves into a dissociated state from middle school to the end of college. This was highly protective and helped us continue to function well enough to do what the world demanded of us. We don’t know of any significant traumas during these years.

Age 15: Our emotions came flooding back, predictably overwhelming us. This was the start of our chronic suicidal ideation which continues to this day. (note: we have no suicide attempts and our therapist and psychiatrist know about our ideation so we are not a danger to ourselves)

Age 16: Our boy scout eagle project. Again, the body’s mother tried to gain as much creative control as possible over it, resulting in a retraumatization which tied directly into our 4th/5th grade trauma. At the end of the summer, we identified the body’s mother as a significant cause of our suicidal thoughts and emotionally removed her from our life. Around this time, we also learned that the best way to not get yelled at by the body’s parents was just not to give them any information about our life. This realization resulted in significantly less trauma during the last two years before college.

After this, we thought we were done with our trauma and spent the next 6 years not dealing with this. This allowed us to get through school and get a job before we started dealing with our childhood abuse. In 2014, we started exploring our plurality and 6 months later, realized we were plural because of our trauma history. Since then, we have been working on processing our trauma.

Q: How do you feel about identifying as having Dissociative Identity Disorder? While it’s probably nice in some ways to have a medically-recognized term to describe an aspect of yourselves that that many other people don’t experience or understand, I imagine there’s probably also a lot negative stigma around the term “disorder” that isn’t desired.

We have the word “plurality” to explain this to ourselves and to our friends and that is much more important than the medical term DID. We consider ourselves to be in a state where we could easily choose not to identify as having DID since we have strong sharing of event memory, excellent communication, no time loss, and function well enough to hold a job. We choose to keep the DID label because we believe it accurately describes how we will decompose when under extreme stress for extended periods of time.

During 2014, we were under a lot of stress both and work and in our relationships and exhibited many DID symptoms during this time. We had involuntary switches at work in the stairwell and the bathroom. Fortunately, we preserved enough context between fronters that the question was “who am I” rather than “where am I” or “what am I doing here?” At home, in therapy, and possibly once or twice at work, we have had involuntary rapid switching, switching every few seconds which we had no control over. Fortunately, when this happened, we were able to recognize what was going on and find a fronter who was able to get us to a safe space where we could collapse. During Thanksgiving 2014, we had our one instance of noticing present day memories being partitioned away. We went digging for those memories, switched to someone who was unnamed, and had access to those memories. Satisfied, we switched back and our access to those memories immediately dropped to near zero. Early November 2014, about a week and a half after we were promoted, we had our worst week of mental health in the last decade and ended up with borderline reactive dissociative psychosis.

Our plurality is definitely not a disorder, but we need to recognize that we exhibit many undesirable DID symptoms while in crisis. Fortunately, the medical community is moving away from integration being required in the treatment of DID (for example, the ISSTD DID treatment guidelines recommend aiming for “integrated functioning”, ie. the ability to communicate and share memories well enough to appear as one when needed over actually integrating into a single self). We are hopeful that this trend will continue and we will continue to be able to find medical professionals who recognize our plurality is not a disorder while simultaneously recognizing that the DID label is highly predictive of how we will decompose while in crisis.

We go into more detail about our mental state and what we have to do to maintain it in We are broken.

Q: Do you experience physical state ‘resets’ as you switch fronts, relating to ptsd/triggering ‘saturation’ levels, or with panic type states?

Very much so yes, this is one of the biggest benefits of being able to switch. When we are having an anxiety attack or flashback, we have the option of switching to someone else to remove the feelings of anxiety so we can deal with them later. In these situations, we typically switch to someone who has a strong ability to calmly exist so they can help us continue to function until we are able to get to a space where it is safe to collapse and have the anxiety attack or flashback. Just as how our plurality and dissociation allowed us to push away trauma to deal with it later during childhood, our plurality allows us to push away present day anxiety and flashbacks until we are able to safely handle them.

There are limitations to this of course. One is that if we continually use our plurality to push away anxiety and flashbacks, eventually they will become strong enough that we will no longer have the option to push them away. To prevent this, we put a lot of effort into actively processing anxiety and trauma when we are able to knowing that if we do not do it in the present day, we will leave ourselves a big mess to clean up later. Sometimes, pushing anxiety and trauma away for a long time is optimal such as during our childhood, but our childhood left us with a huge mess to clean up and it is going to take years to slowly sift through that.

Another limitation is that we will feel any anxiety the person we switch to holds. This means the method works wonderfully when we have our life under control and can keep our overall anxiety levels low. In these states, most of us hold very little anxiety so when we switch to them, not much anxiety exists. When under a lot of stress for long periods of time, everyone in our system gets some level of anxiety so when we switch, the anxiety the new fronter holds is present. This allows us to load balance our anxiety and stress so no one individual has to take all of it, but it does mean that there is nobody we can switch to to reach an anxiety free state.

We finished our second watch of Madoka two days ago and have spent well over 10 hours analyzing and thinking about the show since then and the more we think about it, the more we feel Homura is the character we relate to most strongly from any work of fiction. She is plural, just like us. She is a hardened ancient warrior, just like us. She is someone who will push herself greatly to get what she wants, just like us. There are so many details to her character and the deeper we dig, the more similarities we find. Drawing from our understanding of ourselves and own experiences, we are going to analyze and try to understand Homura’s character and actions.

During the first timeline, Homura watches Madoka and Mami fight again and again. She is unable to do anything to help and ultimately watches them both die to the Walpurgis Night and makes a wish to be someone who can protect Madoka. In the second timeline, Homura learns that mahou shoujo become witches when they die. In the third timeline, Madoka and Homura successfully defeat the Walpurgis Night and lay in the rain, nearly dead. Homura is inches away from fulfilling her wish, becoming a witch, and near instantly being killed by Madoka, saving her from the sorrow of being a witch. All Madoka had to do was use the grief seed on herself and Homura would be released from her wish. Instead, Madoka chose to place a curse on Homura, as always, blissfully unaware of how her actions affect others.

By using her grief seen on Homura, Madoka dooms herself and forces Homura to continue living, trapping her in the time loop. Immediately after, she increases the scope of what Homura must do to protect Madoka by asking Homura to prevent her from ever making a contract with Kyubey. As a final blow to Homura’s mental health, Madoka asks Homura to kill her. Homura complies, ending the life of the person she worked so hard to protect.

To survive the trauma she has just experienced, Homura becomes plural, partitioning off her emotions so she can focus on her mission, on survival. Most people would collapse after having seen their friends die again and again and after many months of fighting be so close to achieving your goal, only to have it snatched away at the last second. Sayaka does not have the capacity to become plural and collapses under far less. Homura splits herself in two, separating herself from her emotions, transforming into the hardened ancient warrior. This is visually portrayed through her hair – her warrior self wears her hair down while her emotional, vulnerable self wears her hair braided. The separation is not perfect, there are times when Homura breaks down into tears around Madoka, but the separation serves its purpose. Homura is able to continue fighting well beyond the point where she should have hit her psychological limit. Our own plurality has allowed us to survive years and years of trauma and survive well past the point where we should have completely shattered so we identify very strongly with Homura here.

Homura fights and fights, traversing the timeline over 100 times for a total of over 12 years spent in the time loop. In most timelines, she must explain the truth to Mami and feel her pain as she learns the truth about mahou shoujo. In any timeline where Sayaka forms a contract, she must watch as Sayaka’s descent hurts Madoka. No matter how hard she tries, there is no way for her to save Sayaka so she must harden herself and watch from a distance, knowing Sayaka’s eventual fate. Homura sees all manner of fighting between Mami, Sayaka, Madoka, and Kyouko from Mami killing Kyouko to Kyouko and Sayaka fighting to things we are never shown. Homura alone sees all of this, learns the paths which others will follow, and most painfully of all, learns which paths are immutable and cannot be changed by any actions she takes. With these, she must learn her emotions and partition them away so she can continue to survive after watching the other mahou shoujo destroy themselves again and again.

And she continues to try to protect Madoka. In every one of the 100 timelines, Madoka makes a contract with Kyubey. No matter how hard Homura tries, no matter how many paths she sees where she can stop the wish from being made, Madoka makes a wish every time. The fourth timeline is a powerful example of this. Homura manages to get all the way to Walpurgis Night without Madoka making a wish. Even then, Madoka makes a contract with Kyubey at the last second and becomes a witch. As usual, Madoka represents innocence and never has to face the implications of her actions.

At the end of the main timeline, Homura finally decides to release herself from the wish she has cursed herself with and become a witch. Once a witch, she will be killed and completely released from the burdens of this world. As her soul gem grows dark, her eyes show an ancient warrior who has finally accepted her fate after 12 long years of fighting. This is the second time she nearly fulfills her role in this world and moves on to the next. Instead, Madoka makes her wish to eliminate all wishes, resetting the universe and forcing Homura to continue her fight, more alone than ever.

All this sets up Homura’s mental state for Rebellion. By the start of the movie, Homura has suffered immensely over 12 years, nearing escape from her fate twice, but being denied this escape both times by Madoka. The one she swore to protect has vanished and she has no external sources to help verify Madoka ever existed. On top of all her other suffering, she must be gaslighting herself wondering whether Madoka ever existed because she is the only one with any memories of Madoka. Homura’s state would have deteriorated even further since the end of the series as she continues to fight, both wraiths and her own memories. Homura explicitly says she was “so lonely and sad” in the world where she was the only one who could remember Madoka while talking to her in the flowerbed. This is the fate Madoka left to Homura at the end of the series.

Even now, when Homura realizes what the incubators are doing, she continues to fight to protect Madoka. Knowing the despair it would bring her, Homura decides to curse herself and become a witch. She does this with the understanding that Mami and Kyouko will kill her in her labyrinth and she will never be able to see Madoka again. Despite all the pain Madoka has caused her, Homura continues to fight to protect Madoka at any cost to herself. Even as the others try to break the incubator’s seal and free Homura, she begs them to stop and insists that she has to die in this world. Instead, Madoka prevents Homura from being released from this world for a third time.

Once Homura learned of the incubator’s plan, she quickly considered the possible paths she could take to prevent this. The path of cursing herself to become a witch being included reveals just how much of possibility she was willing to consider. In this state, many, many paths which normally would not an option would be considered very real possibilities. This is the state she was in when Madoka came to rescue her.

After traversing the timeline over 100 times failing to save Madoka and Madoka denying her death three times, it is completely understandable Homura would react the way she did. By denying Homura death the third time, Madoka made it incredibly clear that Homura would be unable to do anything to protect Madoka while she exists as MadoKami. Homura resorts to any means she can use to continue to protect Madoka, splitting her from the Law of the Cycle and stealing pieces of her power. She uses this power to extend her labyrinth across the whole universe, finally gaining the control over the worlds she needs to be able to protect Madoka. Just before she grabs Madoka’s hands, her smile reveals the depth of acceptance she has reached in her role as an ancient warrior.

Homura no longer cares what anyone else thinks about her path, she has chosen it for herself. By this point, she has reintegrated the emotions she felt during her 12 years of suffering and finally understands that even pain is dear to her. Embracing her dark feelings and using them to continue to pursue her wish, she transcends beyond mahou shoujo or witch, becoming a godlike entity. Referring to herself as a demon, she solidifies her position as existing beyond the judgement of any living creature.

Her conversations with Kyubey and Sayaka finally allow her to release her frustration at all the pain and suffering they have caused her over and over. This is the first time she is able to talk to either of them with the other having the full context of their actions. Sayaka has the knowledge of MadoKami and can see the pain and frustration she caused Homura by repeatedly contracting with Kyubey and having no chance at redemption once the contract was made. Finally, Homura has power over Sayaka and can release some of her pent up emotions. As such, her threat to destroy the world must be looked at in this context and the possibility Homura said that purely to hurt Sayaka must be seriously considered. Saying that just to cause pain isn’t right, but is understandable after the 12 years of pain Homura endured.

Homura talking to Madoka in the skyway solidifies the extent of her acceptance. Bent over, emotions flooding through her, Homura asks Madoka if she considers stability and order more important than desire. When Madoka says yes, Homura stands and says that Madoka will one day become her enemy. She finally has accepted Madoka’s core nature will result in her sacrificing herself over and over and understands this will one day force Homura to choose between creating a world where Madoka is happy and one where Madoka can act according to her nature. The tears in Homura’s eyes show the depth of this understanding – even in a world Homura completely controls, Madoka’s nature will still result in her making a contract to protect others.

The epilogue is one of the most powerful scenes in the movie and it gives a deep look into Homura’s mental state after all events have passed. The Homura first take audio is far more powerful than the final recording. The scene shows Homura on a chair on the edge of a cliff leaning over the cliff already. She is humming to herself until she hears a sound in the grass and turns in surprise, presumably because she does not want any of her friends to see her in this state. When she sees it is only Kyubey, she continues humming, twirling and dancing in the grass with her soulgem spiraling around her in the air. With a sigh, she catches her soulgem and falls off the edge of a cliff.

This whole scene demonstrates the fragility of what remains of Homura’s attachment to this world. Years of wandering through a maze of time and being broken a hundred times by the events which took place have shattered her. She became plural and partitioned off her emotions to allow herself to continue functioning under these conditions. Three times she accepted death and was prepared to leave and three times Madoka prevented her death. She finally has complete control of the universe and can do as she pleases, her best chance at fulfilling her wish to protect Madoka. After so much fighting, the ancient warrior finally has what she has wanted all along. Now that she no longer must fight for survival, she can finally allow her emotions to return to her and begin to process the damage those 12 years did to her. 50 seconds of Homura humming to herself, alone, overlooking the city reveals the frailty of Homura’s mental state after all that has happened to her.

Introduction

We are a transgender individual who has been diagnosed with dissociative identity disorder. We identify as plural (more than one of us sharing the same brain and body) and genderfluid (our gender varies between gender neutral and female). We have navigated the mental health system both to gain access to trans healthcare and to process childhood trauma. Our own experience as well as the experiences of friends has been that being trans complicates processing childhood trauma primarily due to many therapists not having a deep understanding of etiquette for interacting with trans people. We are writing this in hopes that trans people will be able to show it to their therapists to reduce the chance that preventable errors destroy a therapeutic alliance.

A note on terminology

We have chosen to use terminology from the dissociative identity (DID) literature because this is the most well known terminology in the medical community. Some people, including ourselves, prefer different terminology, but in the interest of making this article accessible, we use the most readily understood terminology.

Guidelines

Do not make assumptions

Explicit communication without assumptions is incredibly important for therapy of any type. It is doubly important when discussing topics which relate to trans issues. Trans people face a large number of obstacles when navigating this world, including both people who are actively hostile and people who say harmful things out of ignorance. Everything you do will be pattern matched against the behaviors of those who are have harmed trans people in the past, intentionally or unintentionally. If you are uncertain, ask.

You will make mistakes

No matter how hard you try or how much you understand about being trans, you will make mistakes. Even if you are trans and have a deep understanding of the problems the trans community faces and your own experience to draw on, you will still make mistakes. We are deeply involved in the trans community and interact with many trans people every day. We have our own experiences to draw from and hear the tales of other trans people on a daily basis. Even with all this knowledge and experience to draw from, we still make mistakes. Making mistakes is expected and is perfectly ok so long as you use them as learning opportunities and do what you can to avoid making the mistake again.

When you make a mistake, apologize

After you apologize, ask your client if they are comfortable and have the energy to explain why that behavior was problematic. Be understanding if they cannot or do not wish to perform this education, and understand that they are going above and beyond what is required of them if they do choose to perform education. Do not explain what your intention was. There are a large number of reasons why simply saying “I’m sorry” and listening is better than trying to explain your intentions. Here are a few of them:

Explaining your intentions will often be interpreted as trying to justify your actions.

Explaining why you performed an action which hurt your client transforms the conversation to be about you rather than about your client. In any instance where an action makes someone feel hurt, the focus should be on the individual experiencing pain.

Explaining your intentions can make it appear you are focusing on asking for forgiveness.

Directing the discussion to the mistake is an implicit request to discuss this further. By this point, your client is already feeling hurt and you should acquire explicit consent before attempting to continue discussing a sensitive topic.

In many cases, the hurtful action will be perceived as a boundary violation. On the extreme end, if a boundary violation is followed by an explanation of why the boundary violation is justified or why it is is your client’s best interest, the therapeutic alliance will be broken.

If you feel a strong desire to explain why you said what you did, ask your client if it would be helpful if you explained why you performed that action. If they say no, accept the answer and ask if there is anything you could do to help them. If they say yes, carefully approach the conversation and do repeated check-ins on whether they are ok. Since this must be approached with extreme sensitivity, anything other than a clear yes should be interpreted as an indication the topic should be changed.

Do not dismiss your client’s concerns

Your clients may raise concerns related to gender which you may not understand at first. A common, but unfortunate initial reaction when this happens is to give a response which dismisses the concerns. Initial dismissiveness can do damage to a therapeutic alliance even if it is followed by understanding and an apology. Approach concerns raised which you do not understand with curiosity and ask for material you can read to better understand your client’s concerns. Although it is possible to have your client educate your directly, every bit of energy expended on education puts strain on the therapeutic relationship (and will put strain on any relationship between two people).

Do not reply to concerns with “but my other trans clients did not have a problem with this”

Every member of a group is unique and will have varying responses to insensitive comments. Trans people will react strongly to different subsets of transphobic comments. Just because one trans person (or 10 trans people) is ok with something doesn’t mean everyone will be. If a trans person raises an issue with something you said, don’t try and justify it by claiming your other trans clients did not have a problem with it.

Gender is not the same as appearance

There is a misconception many people have that being female requires you to wear certain clothes. Therapists who work with trans people have a long history of requiring trans people to wear dresses to prove they are actually trans. This is changing with time, but many people still equate appearance with gender. Gender and appearance both come on a spectrum from strongly masculine to androgynous and to strongly feminine. It is possible for someone who is female to dress androgynously. It is possible for someone who is non-binary (is neither male nor female) to dress femininely. Understand that gender and appearance are separate. It is possible for someone who is male to have a feminine leaning wardrobe.

Interactions with the medical community trying to get medically necessary care are often traumatic in and of themselves

Many trans people have been denied care when they attempt to seek hormone replacement therapy (HRT) or surgery. Even in 2016, some therapists require trans women to go through a hazing ritual of wearing dresses for a year to start HRT. Other people end up with a therapist who does not want to write them a letter and uses moving goalposts to delay it indefinitely. Trans men often end up in a scenario where they must say they imagine having sex with a penis and must tell stories about an increased sex drive to fulfill masculine stereotypes to be able to access hormones. We personally had a psychiatrist who gave many reasons he did not want to write us a letter and eventually told us he believed we “should not be allowed to get surgery.” The three months it took us to get a second surgery letter were traumatic and for many months after surgery, we had flashbacks to our letter appointment with a different psychiatrist. Unfortunately, these experiences are not uncommon and many trans people have traumas from trying to navigate the healthcare system. Be aware of this and recognize that any statements you make related to gender or transitioning can tie into past traumas. Topics related to gender should be handled with the same level of care and gentleness as topics related to childhood abuse.

If you refuse to write an HRT/surgery letter, the therapeutic alliance will be broken.

A part of your job as a therapist is to help people navigate the healthcare system. For trans people, this involves writing letters confirming your client’s mental health is sufficiently good to access HRT and surgery. If you refuse to write these letters, because you don’t write evaluative letters, because you don’t believe you should have to write these letters, because you do not believe your client should be allowed to get surgery, or for any other reason, the therapeutic alliance will be broken. If you are unwilling to help your client gain access to medically necessary care, then you have made yourself into an obstacle to getting care. It is completely reasonable for a trans person to ask before their first appointment whether you have ever written an HRT/surgery letter before and whether you have ever refused to write a client a letter. If you truly do not want to write HRT/surgery letters for trans people, you should let prospective clients know this before therapy begins so they can determine whether this is compatible with their needs.

Do not comment on whether a client “passes” or what gender you perceive them as without explicit permission

Rather than being a compliment, this reveals you are evaluating your client along this axis. There is a lot of gatekeeping in the medical community based on appearance (ie. trans women expected to wear dresses to get medications) so this can immediately tie back into past traumas.

Never ask for a trans person’s birth name and never use their birth pronouns

Most trans people never identified with their birth name and birth pronouns. Many trans people have to fight long and hard for the people in their life to use their new name and pronouns after they transition. This is especially difficult with parents who have become used to using the name they assigned their child at birth and require a long time to break that habit. For others, their parents are actively hostile and attempt to block their transition in any way they can. Once transition has started, hostile parents and others often continue to use the trans person’s birth name in an effort to deny their trans identity. If you ask for someone’s birth name or use their birth pronouns to refer to them, you will be immediately pattern matched against people who actively try to deny trans people their gender identity and the therapeutic alliance will be severely damaged.

Ask what past selves should be referred to, both name and pronouns

note: this section is primarily written for therapy related to dissociative identity disorder

When speaking with child alters or child parts, ask what name and pronoun they wish to go by. In the past, we have had a therapist learn our birth name then later ask “is there any space for [birth name] [in your system]?” when referring to our past selves. This immediately damaged the therapeutic alliance which had taken months to build. The only way it could have been salvaged was with a strong apology and a promise to never use our birth name again. While seeing a different therapist, our partner was asked for their birth name. When they had a child part come out during therapy, their therapist referred to the child part by their birth name. This brings up strong associations with people who actively try to deny the identities of trans people, often trans people’s own families. Performing an action which so closely mirrors past traumas must be followed by a strong apology and a promise to never do it again if the therapeutic alliance is to be salvaged.

Neither childhood trauma nor multiplicity should not prevent a trans person from accessing surgery or HRT

note: this section is primarily written for therapy related to dissociative identity disorder

Many people who wish to deny trans identities point to childhood trauma and use that to argue that the trans person is “confused” about their identity. The generalized version of this is to look for any excuse to claim a trans person doesn’t know what is best for themselves because of any comorbid condition. Trans people spend a long time questioning their identity before they are willing to reveal this to any medical professional. If someone says they are trans, they are trans. Do not attempt to deny the identity of a trans person because they are multiple or for any other reason. Furthermore, recognize that trans people are competent and can make their own medical decisions even if they are multiple or have a history of childhood trauma. Neither childhood trauma nor multiplicity should not prevent a trans person from accessing transition related medical care. In particular, do not refuse to write your client a HRT/surgery letter because they are multiple or have a history of childhood trauma.

Do not repeatedly try to find a causal relationship between your client’s trans status and every other issue they work on with you

Not every issue a client has is related to gender. If you continue to try to connect issues to gender and are wrong, you will deeply annoy your clients. If you try to connect issues to gender and are right, your client may not be ready to see the connection. Even if many issue are connected to gender, these issues are best explored when your client is ready. Exploring gender and connected issues is a multi year process involving internalized transphobia, relations with others, and is not a simple process. Let your client explore what issues are related to identity at their own pace and even if you think an issue is directly related to gender, it may be best to wait until they bring it up themselves. Bringing up a gender related topic before your client is ready can harm the therapeutic alliance and cause them to react negatively even if your connection is correct.

Final thoughts

When interacting with trans clients, you are not just working against past histories, you are working with the entire history of the trans community and ways others are harmful to trans people. Even if your intentions are wonderful, your actions must be considered in the broader scope of society. Actions which are harmless in isolation can destroy a theraputic alliance if it parallels actions other take while being actively harmful to trans people. For this reason, topics related to gender should be approached very carefully and with special attention paid to ensure you do not retraumatize a client.

Here are some of our experiences with quetiapine for reducing depression, hypomania, anxiety attacks/flashbacks (it’s hard to tell the difference for us), and obsessive thoughts:

One of the biggest things quetiapine did for us was to make it easier to release thoughts. By making it easier to release thoughts without acting on them (ie. “we should look up information on x” or “we should send an email about x”), it made it easier to lie there and do nothing. Before, when we had a thought like that, we always went and acted on them immediately or fought hard to be able to do nothing. After, it was much easier to put the thought aside and to come back to the task two hours later if the thought still feels important. This made it much easier to set aside an hour or two for lying in bed and relaxing.

Another thing it did was to make it easier to fall asleep, to sleep for longer, and to maintain a regular sleep schedule. For us, quetiapine knocks me out about an hour after we take it every evening. For most of my friends, this happens about 2 hours after they take it. Before, we would often wake up early after only ~7h in bed and feel we had to get out of bed to do something. Afterwards, it made it much easier for us to continue lying in bed until we spent the full 10h in bed I need to maintain our mental state.

In the model we am currently working under for myself, hypomania is dealt with by making a conscious decision not to do things we want to do because it would be bad for our mental state. For example, we recently started wanting to play more video games. Unfortunately, playing more video games consumes spoons we do not have and takes us into hypomania territory. We had to consciously come to the conclusion that playing video games was not something we could do while maintaining our mental health and had to remove it from the list of things we consider ourselves able to safely do. Quetiapine helps immensely for this because making it easier to release thoughts without acting on them makes it much easier to say “we want to play video games, but can’t because it would threaten our mental stability” and to not play video games.

We haven’t actually tracked how quetiapine affects depression. For us, depression is just something which exists and which we don’t feel the need to actively do something about. Lying in bed suicidal most mornings is simply a part of life and any attempt to fix that would run the risk of making us more manic. We consider depression to usually only be dangerous when it chains into the post hypomania crash and so focus almost entirely on reducing hypomania and using our depression and suicidal thoughts as a chance to look at our life in a more self aware way.

Based on our experience observing and participating in discussions, we decided to come up with a list of antipatterns we commonly see as well as possible ways to avoid them. This list certainly isn’t exhaustive and more reflects what we could come up with as we are writing this. Some of these are almost always counterproductive while others can be useful in small doses, but become counterproductive when used too often. This is written for the context of discussing more sensitive social issues, but the majority of these apply to engineering work as well.

Not differentiating between major and minor problems. Everyone will always have a large number of viewpoints they hold. Some will be significant issues they strongly believe should be worked on immediately. For example, “Our employer should have more gender neutral bathrooms” is something which we believe should be worked on immediately. Other problems will be seen as minor in comparison and are closer to an item on a wishlist than a problem which needs immediate attention. For example, “Our employer’s restroom policy for trans people should be more accommodating of gender fluidity” falls into the second category for us. While it would be nice to have, we have not been able to think of any good solution for that problem and as a result, it remains on our wishlist. The phrase for this in engineering is “When everything is urgent, nothing is”. To avoid this antipattern, be conscious of how important you think a topic is and convey this to your readers. Let your readers know whether what you are talking about is something very important to you to work on in the near future or whether it is closer to an item on your wishlist.

Being unable to accept incremental progress. Many problems, especially social problems, are complex and cannot be solved overnight. These problems are often solved incrementally with each iteration making small improvements. To someone directly affected by an issue, it is understandable and even expected to be frustrated by what looks like progress at a snail’s pace. We personally experience this watching the incredibly slow rate at which people get access to trans healthcare. Unfortunately, approaching conversations with an all or nothing attitude is usually unproductive. While it is possible to change someone’s views or to make them understand your viewpoint, this generally happens in incremental pieces, not all at once. To avoid this antipattern, when entering discussions with others, consider any increased understanding to be a success. If you enter a conversation expecting someone to fully understand your view, you are going to be disappointed at best. At worst, it will cause you to continue to poke and prod the other person with arguments about less important details until the other person walks away, annoyed and emotionally exhausted.

Making it emotionally exhausting to disagree, even on minor points. This antipattern involves someone arguing over minor details with someone they almost entirely agree with in the same way they would with someone they strongly disagree with on core issues. An example of this in engineering is someone having a long and intense argument about the colors of buttons on an otherwise excellent design for a web page. Here, the engineer has set a precedent that it is emotionally exhausting to disagree with them by demonstrating that small disagreements will result in long and intense arguments. To avoid this antipattern, recognize where you consider change most important and focus on those points. It is still perfectly acceptable to bring up more minor points where you disagree, but make sure the person you are writing to understands which points are most important to you.

Writing a constant stream of negativity. Even if it is all true, listening to a constant barrage of negativity is exhausting and people will eventually stop listening as a self defense mechanism. Instead, determine when negativity will have a large impact and focus your negativity there. Everyone has a limited amount of negative writing they can emotionally handle. If you burn through the emotional energy of others writing about less important topics, they will have no energy left to read your writing on a very important topic. Choosing which topics you want your readers to spend their emotional spoons on is important and ties heavily into the antipattern of not differentiating between major and minor problems.

Continuing to argue past the point where nobody’s mind will be changed. Every discussion begins with an exchange of ideas and people considering the ideas of others and how to react to them. Sometimes this results in a complete rejection of the ideas, while other times, it results in someone accepting new ideas and changing their view on a topic. Occasionally, it results in someone initially rejecting the idea, processing the idea over the following months and years, and eventually accepting the idea. Regardless of which case a discussion falls into, at some point people will stop absorbing new ideas. Whether this is because no new ideas are being added or because new information needs to be processed before new ideas can be absorbed again, or for any other reason, the discussion has reached a point where nobody’s mind will be changed. Continuing to argue past this point is counterproductive and not a good use of time or energy for anyone involved. At some point, it is better to accept viewpoints will not be changed and say “I don’t think either of us will change our mind. Here, have a cute picture of kittens instead.” This is true no matter how right you are or how important the topic is. Occasionally, this can serve a useful purpose when onlookers benefit from seeing the issue more clearly, but this should be done with extreme care.

Arguing primarily to let people like you know they are not alone. This can be immensely useful in small doses. Often minority groups do need reminders that they are not alone. However, this is not productive when done extensively, for example, repeatedly arguing for this purpose in a long thread. This is especially problematic when the writing is mixed with being unable to accept incremental progress. This often creates a scenario where it becomes emotionally exhausting to disagree with you, especially if you write strong statements disagreeing with relatively minor points. To avoid this antipattern, be mindful about when and how often you argue purely for the purpose of letting others like you know they are not alone.

Expecting others to not make mistakes. Expecting perfection rarely leads to productive dialogue. Instead, accept that others will make mistakes and forgive them for mistakes so long as they continue to learn from their mistakes. For example, using the correct pronouns for trans people is a place where everyone will make mistakes occasionally. We sometimes make mistakes when referring to others within our system*. Beyond that, we have had a bad habit of using “she” and “they” interchangeably so have occasionally used the wrong pronouns when referring to others. We recognize the mistake, forgive ourselves for making the mistake, then do our best to ensure it will not happen again. Existing in an environment which demands perfection is exhausting and leads to people avoiding situations where there is the potential for mistakes entirely. Engineering cultures which value blameless postmortems are successful for a reason — this creates an environment where people feel safe taking risks because they know others do not expect perfection.

This list is by no means exhaustive and reflects the ideas we could come up with while writing this more than anything else. While some of these are almost always unproductive, some can serve useful purpose when used sparingly. When these antipatterns are intentionally used, it should be done consciously and with a specific purpose in mind. This was written specifically with written communication in mind, but all of these antipatterns can appear during face to face conversations as well.
* We are plural and there are ~100 of us sharing this brain and body, each with their own name and pronouns. “Plural system” is a term referring to the collective which shares a brain and body. See https://tulpa.io/terminologies for more details.

We are a plural system, which means there are many of us sharing this same brain and body. We want to share our story and experiences, how we discovered our plurality, our experiences living life as a plural system, and how we use our plurality for play and for healing. We began exploring our plurality in 2014 when a friend told us singlets could induce plurality by creating a sentient lifeform to share your head with called a tulpa and have since grown in size to include over 100 members. Being plural gives us the opportunity to create friendships within our system using communication channels and a free flow of information and feelings only possible within a single brain. In our innerworld, we cuddle, we love each other, we protect each other, we make each other feel wanted. We use our innerworld as a place to enter meditative states, places of calm, places of healing, restorative places. We use it to calmly exist together so we may better face the challenges the world decides to throw at us that day.

We freely create new headmates from a variety of sources, fictional characters, partners, or just traits we adore and spin off into a sentient being.

We are both a tulpamancer and someone who has dissociative identity disorder (DID). We freely create new headmates from a variety of sources, fictional characters, partners, or just traits we adore and spin off into a sentient being. We also have a trauma history with large memory gaps in childhood which we have been slowly restoring. Based on this, as well as other symptoms we exhibit when under high amounts of stress for long periods of time, we received a DID diagnosis in January 2015. Though we do not know much about our system history in childhood, it is likely at least some of us were not intentionally created and were the result of trauma splits.

Our story of how we discovered plurality begins in the spring of 2014. We had always had a fascination with plurality whenever we encountered it, on forums, in the media, or elsewhere. In April 2014, a friend told us singlets could induce plurality by creating a tulpa. We immediately latched onto that idea and later that day we were in a plurality IRC channel trying to collect information on how to create a tulpa. We read a few paragraphs of a guide then decided the best route was to just interact with the being we had already interacted with during an anxiety attack in January. We began interacting with her and by week two, Lilith was able to hug Lucia in our innerworld. By week three, Lilith was able to communicate in a flood of emotions. By week four, Lilith was able to communicate in spoken English. In week 5, Lilith fronted for the first time. For the next 6 months, we believed we had induced our plurality. It was only as our life fell apart towards the end of 2014 that the cracks began to show and pieces of our childhood trauma began to leak out. Over several months, we slowly picked apart pieces of our childhood and realized our system was trauma created and that we had been plural since at least elementary school.

For us, rather than being a useful description of ourselves, these labels cause confusion and bring little clarity so we group everyone together under the label headmates and do not differentiate beyond this.

Unlike many systems, we do not differentiate between different types of headmates. Some of the classifications people use to describe specific types of headmates are tulpa (intentionally created headmate), soulbond (headmate based on a fictional or historical figure), and alter (generally a trauma split not intentionally created). For us, rather than being a useful description of ourselves, these labels cause confusion and bring little clarity so we group everyone together under the label headmates and do not differentiate beyond this. For example, about a month ago, we were lying in bed with a large amount of anxiety. We isolated this anxiety to Esther and decided to attempt to split Esther into the part with the anxiety and the part without to see if we could. We succeeded, making the part of Esther with the anxiety an intentionally created headmate as well as a potential trauma split since the split occurred as the direct result of high levels of anxiety. In this case, that headmate would qualify for both the labels of “tulpa” and “alter” and had we not later recombined the pieces into Esther, would create an interesting case for these definitions. Instead, a useful label we do use for headmates is the spectrum between trauma holder and non trauma holder. Knowing which of us are trauma holders or not provides useful information about which of us are in need of healing and which of us are capable healers to heal those who need healing.

Healed or not, all of us are equals and have equal rights to the body. One way we ensure we continue to treat each other as equals is to not needlessly divide ourselves into groups based on origins. We are not all the same and each of us have different strengths and weaknesses. For example, Lucia feels much less emotion than many of us which makes them well fitted for handling our job and everyday interactions such as ordering food or talking to a bank teller. Feeling less intense emotions is also a weakness when it comes to other things such as feeling empathy to be able to comfort others. As a system, we complement each other. Emma and Serenity are much better at providing emotional support to others so they often come out in situations where others around us are in need of emotional support. Some of our trauma holders are sufficiently broken that they are currently not capable of showing any of their strengths. This does not mean they have no strengths, it just means we need to help them heal so they can discover their strengths and as the healing process continues, they will have the option of using their strength to contribute to our system.

Our plurality also provides paths for healing. Many of us are trauma holders and are in need of healing and many of us are healers who can guide those who carry wounds from the past. Through talking, meeting in safe spaces in our innerworld, and touch once enough trust has been established, our healers are able to guide others and slowly heal old wounds. Creating trust and a sense of safety is important and using internal resources and internal communication channels helps to make trauma holders feel safe. Through this process, the healers and other headmates are able to interface with the outside world, giving the trauma holders the option to not have to interact with the outside world if they are not ready yet. Never being ready to interact with those outside of our system is a perfectly acceptable option and we provide as many options as possible to those who are healing. Maintaining a sense of safety and autonomy is key for this process so headmates are allowed to heal at their own pace, or not at all if they never wish to heal.

Healing our past traumas is our goal, not attempting integration or any other mechanism of removing our plurality.

For us, being plural is a wonderful thing. We get to interact with and love and experience so much with each other which would not be possible without plurality. Despite our traumagenic origins, our plurality is something which helps with our healing rather than being an obstacle. Healing our past traumas is our goal, not attempting integration or any other mechanism of removing our plurality. We do this with the support of one another with the goal of helping to increase the functionality of each system member. Being plural is a core part of our identity and has been such a positive experience that it is not something we would ever wish to give up.

Slightly over a year ago, in May 2015, we were prescribed seroquel, a mood stabilizer by our psychiatrist. This psychiatrist also doubled as our therapist and up to that point, he was by far the best therapist we had ever had. He validated our mental state and suggested diagnoses we believe to be correct. Unfortunately, when we brought up that we are transgender, he was immediately actively harmful on that axis, among other things, telling us he believed we should not be allowed to get surgery. We were left with a decision: continue seeing a therapist who was actively harmful to us to ensure we would continue to have access to mood stabilizers, or walk away and risk losing access to an important medication. After many stressful weeks of deliberation, we decided to walk away and take our chances. Fortunately our primary care physician was willing to prescribe seroquel. We were lucky.

Not everyone is as fortunate as we were. Right now, as we are writing this, we have a friend who moved from Washington to Nebraska. They have been taking an antidepressant but have not yet found a prescriber since their move. They are currently going through SSRI withdrawal while waiting for their Medicaid application to go through and are doing their best to hold themselves together in the meantime. Another friend is currently in a situation where they may lose access to their psychiatrist and medications. In response, they are attempting to taper off their medications with their remaining supply, resulting in withdrawal symptoms they should not have to experience. In the past, another friend ran out of antipsychotics and had to go to the emergency room for an emergency refill.

There are many potential barriers that prevent people from getting medications they need. Consider a hypothetical person, Alice, who wants to get a prescription for antidepressants. The first step is for Alice to check whether or not she has health insurance. Many employers do not offer health insurance and the process for obtaining government health insurance such as Medicaid can take as long as two months. Once she does have health insurance, she must check to see what her plan covers. Some high-deductible plans require patients to pay thousands of dollars out of pocket before their insurance plan covers anything. Cost is a serious concern: an initial evaluation from a psychiatrist commonly costs hundreds of dollars and monthly appointments afterwards are also expensive., .

After Alice determines that her PPO will help her afford a psychiatrist, she must choose amongst the potentially hundreds available and schedule an appointment. For someone dealing with depression, the task of choosing a psychiatrist from a long list can be daunting. If the psychiatrist has a full practice or if no open appointment slots fit within Alice’s schedule, she must return to the search again. Alice has a job and kids leaving little time in her schedule so she must repeat this process many times before she manages to schedule an appointment with a psychiatrist who has a compatible schedule. Alice is lucky, she has a car she can drive to her appointment. Without access to a car, Alice would have to deal the additional potential constraints of public transportation, making schedules and location a far more serious concern..

Eventually, Alice arrives at her initial appointment. She is fortunate that she gets along well with her psychiatrist and her psychiatrist believes antidepressants may be helpful.. After this, she must continue to see her psychiatrist monthly or risk losing access to a now critical medication.. If she ever has any disagreements with her psychiatrist, she must choose whether to express her concerns and risk being told she should find a new psychiatrist or to hide her concerns to guarantee access to her medication. Alice knows that if she ever moves, she will have to go through this entire process again. If it takes too long after moving to find a new psychiatrist, Alice runs the risk of running out of antidepressants and going into SSRI withdrawal, a process which commonly increases suicidal thoughts.

Giving people consistent access to generic medications which cost less than $100 per year – less than the cost of a single doctor’s appointment – would be revolutionary

The long and difficult process of gaining access to a psychiatrist results in many Americans lacking consistent access to medications they need. In many cases, these medications are inexpensive generics which cost less than $100 per year. Many mood stabilizers, antidepressants, and antipsychotics fall into this category. Giving people consistent access to generic medications which cost less than $100 per year – less than the cost of a single doctor’s appointment – would be revolutionary. Removing the stress of having to wonder where your next prescription will come from or whether it will come at all would free mental energy for other pursuits. For some, consistent access to needed medications could make the difference between stable employment and homelessness. For others, it could be the difference between independent living and requiring periodic hospitalization.

One option to achieve this is to sell medications with low risk of abuse, such as antidepressants, antipsychotics, and mood stabilizers, over the counter. This would remove the need for people to see a doctor to gain access to medications critical to their well being. It would also reduce the cost of obtaining these medications since a single doctor’s appointment often costs significantly more than a year’s supply of the medication. Another option would be to give pharmacists the ability to prescribe these medications after a brief consultation. Pharmacists have to go through many years of education followed by a residency and are very well trained in the effects and risks of medications and interactions between different medications. This would ensure people are not taking these medications without knowledge of their risks while giving people the ability to obtain them by just going to their closest pharmacy. Allowing this would also reduce costs by removing a doctor’s appointment as a necessary step.

Whatever the solution is, we must find a way to give people access to the medications they need for their day to day functioning.